Endoscopic ultrasound-guided fine-needle aspiration results in upper gastrointestinal system mesenchymal tumors

Abstract

Background and Aims: Gastrointestinal mesenchymal tumors have characteristic

endoscopic and endosonographic imaging findings, whereas endoscopic

biopsies are usually not helpful for diagnosis. Endosonography-guided

fine-needle aspiration biopsy might allow the procurement of samples

from the lesion. We report retrospective results and efficiency of endosonography-

guided fine-needle aspiration in upper gastrointestinal mesenchymal

tumors. Materials and Methods: Patients admitted to our endosonography

unit with pre-diagnosis of upper gastrointestinal system mesenchymal

tumors between 2009 and 2010 were evaluated. Patients who underwent

endosonography-guided fine-needle aspiration (n=27) were included in the

study. The cytopathology specimens were evaluated by two blinded pathologists.

The final diagnoses were recorded. Results: Eighteen male and 9 female

patients with a mean age of 52.6±12.1 years (30–84 years) were included

in the study. Lesions were located in the esophagus in 14 patients and in

the stomach in 13 patients. The mean lesion diameter was 29.5±15.6 mm

(7-57 mm). Endosonography-guided fine-needle aspiration procedures were

performed by two gastroenterologists. Cytopathology specimens were evaluated

and the presence of spindle cells was reported in 14 samples (51.8%).

Out of 14 samples, two were reported as malignant gastrointestinal stromal

tumors, whereas 4 specimens were reported as suspicious for mesencymal

tumors. Immunohistochemistry for CD117 was applied to nine specimens

and two samples were positive. Malign gastrointestinal stromal tumor was

reported in two patients. Those two patients also had pathologic lymph node

metastasis and endosonography-guided fine-needle aspiration was applied

to the lymph nodes as well. Repeated endosonography-guided fine-needle

aspiration was applied to three samples and with repeated fine-needle aspiration,

the overall diagnostic efficiency of endosonography-guided fine-needle

aspiration in upper gastrointestinal mesencymal tumors reached 59.25%.

Conclusion: Endosonography-guided fine-needle aspiration supports the

diagnosis of mesencymal tumors in 51.8% of patients. With repeated endosonography-

guided fine-needle aspiration , the diagnostic yield was 59.25%.

Although endosonography is very helpful in the diagnosis of mesencymal

tumors, endosonography-guided fine-needle aspiration adds less to the definite

diagnosis.

Keywords

• Gastrointestinal mezencymal tumour,endosonography,fine needle aspiration

Üst gastointestinal sistemde mezenkimal tümör düşünülen olgularda endosonografik ince iğne aspirasyon biyopsi sonuçları

Öz

Giriş ve Amaç: Gastrointestinal mezenkimal tümörler belirgin endoskopik

ve endosonografik özelliklere sahip olmalarına karşın histopatolojik tanıda

endoskopik biyopsinin başarısı düşüktür. Endosonografik ince iğne aspirasyon

biyopsisi lezyonlardan daha derin örnekleme olanağı sağlayan bir yöntemdir.

Bu çalışmada retrospektif olarak üst gastrointestinal sistem mezenkimal

tümörü düşünülen ve endosonografik ince iğne aspirasyon biyopsisi

uygulanan olguların sonuçları irdelenmiştir. Gereç ve Yöntem: Çalışmaya

2009-2010 yıllarında kliniğimize başvuran ve üst gastrointestinal sistem mezenkimal

tümor şüphesi ile endosonografik ince iğne aspirasyon biyopsisi

uygulanan 27 vaka dahil edilmiştir. Olgularda tanımlanan lezyonlardan alınan

endosonografik ince iğne aspirasyon biyopsisi materyalleri sitopatolojik

incelemeye gönderilmiştir. Materyaller iki ayrı patolog tarafından değerlendirilerek

materyalin yeterliliği ve tanı bildirilmiştir. Bulgular: Çalışmaya

yaş ortalaması 52.6±12.1 yıl (30-84 yaş aralığında) olan 18 erkek, 9 kadın

dahil edilmiştir. Lezyonların 14’ü özofagus, 13’ü midede yer almaktadır ve

ortalama çap 29.5±15.6 (7-57 mm) ölçülmüştür. Lezyonlara uygulanan endosonografik

ince iğne aspirasyon biyopsisi sonucu elde edilen materyalin

sitopatolojik incelemesinde 14 adedinde (%51.8) iğsi hücreler görülmüştür.

Bunlardan 2 olguda malign davranışlı gastrointestinal stromal tümör tanısına

ulaşılmış, 4 olguda mezenkimal tümor açısından kuşkulu sitoloji bildirilmiş,

kalan 8 olguda iğsi hücre toplulukları görülmüştür. Dokuz olguda hazırlanan

hücre bloklarına immünohistokimyasal olarak CD117 boyası uygulanmıştır.

Malign gastrointestinal stromal tümör tanısına ulaşılan olgularda

midede mezenkimal kitle ve perigastrik lenf nodu metastazı saptanarak her

iki lezyona endosonografik ince iğne aspirasyon biyopsisi uygulanmıştır. Üç

olguya ikinci kez biyopsi uygulanmış ve iki olguda iğsi hücreler görülmüştür.

Bu olgularla birlikte tanı oranı %59.25’e ulaşmıştır. Sonuç: Gastrointestinal

mezenkimal tümörlerde endosonografik ince iğne aspirasyon biyopsisi,

tanıyı %51.8 olguda destekler bulgular vermiş, iki olguda malign gastrointestinal

stromal tümör tanısına ulaşılmıştır. Tekrarlayan endosonografik ince

iğne aspirasyon biyopsisi ile tanı oranı %59.25’e ulaşmıştır. Sonuç olarak

üst gastrointestinal mezenkimal tümörlerde endosonografik inceleme oldukça

yararlı iken endosonografik ince iğne aspirasyon biyopsisi tanıya yeterli

katkı sağlamamaktadır.

Anahtar Kelimeler

• Gastrointestinal mezenkimal tümör,endosonografi,ince iğne aspirasyon biyopsisi

Kaynakça

1. Nevin Oruç - Pidhorecky I, Cheney RT, Kraybill WG, Gibbs JF. Gastrointestinal stromal tumors: current diagnosis, biologic behavior, and management. Ann Surg Oncol 2000;7:705-12. 2- Okai T, Minamoto T, Ohtsubo K, et al. Endosonographic evaluation of c-kit-positive gastrointestinal stromal tumor. Abdom Imag 2003;28:301-7. 3- Shah P, Gao F, Edmundowicz SA, Azar RR, Early DS. Predicting malignant potential of gastrointestinal stromal tumors using endoscopic ultrasound. Dig Dis Sci 2009;54:1265-9. 4- Oruc N, Aydın A, Tekin F, et al. Üst gastrointestinal sistem stromal tümörlerinin endosonografik ve histopatolojik özelliklerinin karşılaştırılması: Tek merkez deneyimi. Endoskopi 2009;17:06-11. 5- Matsui M, Goto H, Niwa Y, et al. Preliminary results of fine needle aspiration biopsy histology in upper gastrointestinal submucosal tumors. Endoscopy 1998;30:750-5. 6- Ito H, Inoue H, Ryozawa S, et al. Fine-needle aspiration biopsy and endoscopic ultrasound for pretreatment pathological diagnosis of gastric gastrointestinal stromal tumors. Gastroenterol Res Pract 2012;2012:139083. 7- DeMatteo RP, Lewis JJ, Leung D, et al. Two hundred gastrointestinal stromal tumors: recurrence patterns and prognostic factors for survival. Ann Surg 2000;231:51-8. 8- Chak A, Canto MI, Rosch T, et al. Endosonographic differentiation of benign and malignant stromal cell tumors. Gastrointest Endosc 1997;45:468-73. 9- Palazzo L, Land B, Cellier C, et al. Endosonographic features predictive of benign and malignant gastrointestinal stromal tumours. Gut 2000;46:88-92. 10- Chatzipantelis P, Salla C, Karoumpalis I, et al. Endoscopic ultrasound-guided fine needle aspiration biopsy in the diagnosis of gastrointestinal stromal tumors of the stomach. A study of 17 cases. J Gastrointestin Liver Dis 2008;17:15-20. 11- Ando N, Goto H, Niwa Y, et al. The diagnosis of GI stromal tumors with EUS-guided fine needle aspiration with immunohistochemical analysis. Gastrointest Endosc 2002;55:37-43. 12- Hoda KM, Rodriguez SA, Faigel DO. EUS-guided sampling of suspected GI stromal tumors. Gastrointest Endosc 2009;69:1218-23. 13- Stelow EB, Murad FM, Debol SM, et al. A limited immunocytochemical panel for the distinction of subepithelial gastrointestinal mesenchymal neoplasms sampled by endoscopic ultrasound-guided fine-needle aspiration. Am J Clin Pathol 2008;129:219-25. 14- Akahoshi K, Oya M, Koga T, et al. Clinical usefulness of endoscopic ultrasound-guided fine needle aspiration for gastric subepithelial lesions smaller than 2 cm. J Gastrointestin Liver Dis 2014;23:405-12. 15- Assef M, Rossini L, Neto GS, et al. Influence of layer, size and organ of subepithelial lesions of upper gastrointestinal tract in outcomes of endoscopic ultrasound-guided fine-needle aspiration. Endosc Ultrasound 2014;3(Suppl 1):S16. 16- Franco MC, Schulz RT, Maluf-Filho F. Opinion: How to manage subepithelial lesions of the upper gastrointestinal tract? World J Gastrointest Endosc 2015;7:1262-7. 17- Na HK, Lee JH, Park YS, et al. Yields and utility of endoscopic ultrasonography-guided 19-Gauge trucut biopsy versus 22-Gauge fine needle aspiration for diagnosing gastric subepithelial tumors. Clin Endosc 2015;48:152-7. 18- Suzuki T, Arai M, Matsumura T, et al. Factors associated with inadequate tissue yield in EUS-FNA for gastric SMT. ISRN Gastroenterol 2011;2011:619128. 19- Fernández-Esparrach G, Sendino O, Solé M, et al. Endoscopic ultrasound-guided fine-needle aspiration and trucut biopsy in the diagnosis of gastric stromal tumors: a randomized crossover study. Endoscopy 2010;42:292-9. 20- Jenssen C, Barreiros AP, Will U, et al. German survey on EUS-guided diagnosis and management of gastrointestinal stromal tumors (GISTs) - evidence or "gut-feeling"? Ultraschall Med 2015;36:494-500.